Laparoscopic Instrument Holders for Surgical SImulation and Training

ABSTRACT

Innovative instrument holders used for minimally invasive surgical simulation and training are disclosed when used in conjunction with a smartphone, tablet or mini-tablet computer enabling visualization of the surgical field. The surgical field used with these instrument holders can include animal models, physical models, and both virtual and augmented reality models. Some embodiments can be used with applications that can be downloaded to the smartphone, tablet or mini-tablet computer in order to enhance specific hand-eye coordination tasks. Some embodiments can be used as an adjunct surgical trainer for endoscopy, colonoscopy, and other minimally invasive gastrointestinal and gynecological surgical procedures using surgical instruments that incorporate fiber optics.

COPYRIGHT & TRADEMARK NOTICE

A portion of the disclosure of this patent document contains material,which is subject to copyright protection. The owner has no objection tothe facsimile reproduction by anyone of the patent document or thepatent disclosure, as it appears in the Patent and Trademark Officepatent files or records, but otherwise reserves all copyrightswhatsoever.

Certain marks referenced herein may be common law or registeredtrademarks of third parties affiliated or unaffiliated with theapplicant or the assignee. Use of these marks is by way of example andshall not be construed as descriptive or to limit the scope of thisinvention to material associated only with such marks.

TECHNICAL FIELD OF THE INVENTION

The present invention relates to innovative instrument holders used forminimally invasive surgical simulation and training when used inconjunction with a smartphone, tablet or mini-tablet computer enablingvisualization of the surgical field.

BACKGROUND OF THE INVENTION

Disclosed herein are innovative instrument holders used for minimallyinvasive surgical simulation and training when used in conjunction witha smartphone, tablet or mini-tablet computer enabling visualization ofthe surgical field. The surgical field used with these instrumentholders can include animal models, physical models, and both virtual andaugmented reality models. Some embodiments can be used with applications(“apps”) that can be downloaded to the smartphone, tablet or mini-tabletcomputer in order to enhance specific hand-eye coordination tasks. Someembodiments can be used as an adjunct surgical trainer for endoscopy,colonoscopy, and other minimally invasive gastrointestinal andgynecological surgical procedures using surgical instruments thatincorporate fiber optics.

Laparoscopic surgery is a minimally invasive surgical techniqueperformed with a specially configured video camera called a laparoscopeand several thin surgical instruments. During the surgical procedure,small incisions have trocars through them of various designs and thelaparoscope and surgical instruments are introduced into the body cavitythrough sleeves in the trocar acting as ports. During the procedure thelaparoscope transmits images of the internal organs and tissues to anexternal television monitor in the operating room. This enables thesurgeon to manipulate internal tissues using instruments introducedthrough the non-video ports in the body cavity without directlyobserving the manipulated tissues except through the transmittedtelevision image.

There are at least three fundamental psychomotor problems inlaparoscopic surgery. First, the surgeon's hands move surgicalinstruments while the surgeon's eyes are averted to an external monitor.The surgeon's eye movement and the movement of the surgeon's hands asdisplayed on the video monitor are not therefore in the same direction.Second, the surgeon's hands are moving in three dimensions whiledisplayed on a two dimensional video monitor. Finally, haptic feedbackusing laparoscopic instruments is greatly reduced. For example, innormal surgery, the surgeon's hands can often detect changes in tissuedensity such as when a tissue is completely cut. However, inlaparoscopic surgery, the completion of a tissue cutting procedure mayonly be evident on the video monitor because of the suppressed hapticfeedback. Overcoming these muted sensory cues and hand-eye coordinationproblems with sufficient competency to perform laparoscopic surgery canentail training exceeding 10 years. A critical element of this training,especially in overcoming altered sensory cues and hand-eye coordinationproblems alluded to above, are the use of training simulators as anadjunct to surgical education.

Laparoscopic surgical education and training currently employ simulatorsranging from simple “box trainers” to sophisticated Virtual Reality (VR)trainers approaching the fidelity of real surgical scenarios. VRsimulators are expensive and are generally fixed installations requiringan Information Technology (IT) infrastructure and IT support personnel.VR simulators also often entail prescribed surgical scenarios withdiminishing pedagogic significance as the trainee replays trainingscripts.

Box trainers range in sophistication and generally include a stand thataccommodates a camera, typically a third party supplied camera internalto another device such as an IPad® or iPhone®. The camera functions as asurrogate laparoscope or even possibly as an external monitor. The boxsimulator may also have instrument holders and possibly alsolaparoscopic instruments integrated with these instrument holders. Thecamera in these box trainers is focused on a physical model or a smallanimal where the instruments can be used to manipulate objects andperform surgical tasks on tissues or physical objects within the visualfield of the camera.

Box simulators are a valuable adjunct to laparoscopic surgical educationoutside the surgical suite in that they are less expensive, may beportable, do not encumber valuable hospital or medical school resources,and can promote development of appropriate hand eye coordination skills.Box simulators, however, are currently limited in representing thesurgeon's interaction with tissue and mechanical manipulation oflaparoscopic instruments. Many box simulators, due to their small size,can only accommodate a limited surgical field and have severelyconstrained instrument motion. Also, because of the eccentric placementof the camera on a third party device, such as an IPad® or IPhone®,parallax errors and unrealistic spacing between tips of surgicalinstruments as compared with a real surgical scenario tend to beapparent in the simulator visual field. Because of their limitedsurgical field, current box simulators also only permit manipulation ofphysical objects or small animals as opposed to surgical tasks on largeranimal models that embodiments of the current invention permit.

Embodiments of the present invention include laparoscopic instrumentholders that compensate for eccentric camera placement, allow for anenlarged visual and surgical field enabling surgical tasks to beperformed on larger animals than current box simulators, is not specificto a particular tablet of smart phone device, provides realistic spacingin the surgical field between surgical instrument tips, and allowsrealistic and unconstrained movement of surgical instruments includingthe camera functioning as a surrogate laparoscope. In other embodiments,a novel device with nested gimbal rings allows augmented realitysimulation of endoscopic, bronchoscopic, colonoscopic, gastroscopic andother minimally invasive surgical procedures when used in conjunctionwith downloadable virtual reality apps of minimally invasive surgicalprocedures. This embodiment can also be used in conjunction withdownloadable apps that are designed enhance hand-eye coordinationprerequisite to many minimally invasive surgical tasks.

Currently, there are at least eight box type laparoscopic simulatorsthat have been developed world-wide. These include: (1) Lap Tab—an IPad®Based Laparoscopic Trainer, (2) a Portable Tablet Box Trainer, (3) aCardboard Box trainer using smartphones and tablets, (4) a Portablelaparoscopic trainer for smartphones and tablets—i.e., Surgical trainerbased on iPhone® Technology, (5) a Cardboard box iTrainer, (6)LapSkills, (7) eoSim, and (8) a Card Board Box iTrainer. Each of thesetrainers is discussed below.

(1) IPad® Based Laparoscopic Trainer (Yoon, Junco, et. al., 2015)—Thisis an open box surgical simulator that uses an IPad® with a third party,commercial “off the shelf” universal supporting base. The system hasintegrated laparoscopic holders in which instruments are inserted. Alimitation of this system is that the holder on the right side of theIPad is located so far from the internal camera lens on the rear of theIPad® that this trainer cannot be used for animal dissections. It alsodoes not allow for use of surgical trocars and the instrument holdersare specific to the IPad®.

(2) Lap Tab—Portable Tablet Box Trainer (Aa, Schreuder, et. al.,2015)—This is a folding open box surgical trainer that uses a tabletcomputer. This trainer provides very limited surgical space and noopportunity to enlarge the surgical field. The system also allows forunrealistic and very constrained movement of surgical instruments.Because the system does not use a tripod, it cannot be easily moved to aconvenient user location.

(3) Cardboard Box trainer using smartphones and tablets (Bahsoun, Malk,et. al., 2013)—This is a simulator with a cavity made from a cardboardbox where the left the side and rear of the cavity is open to allow fornatural light to fill the cavity. An IPad 2® is placed over the box toact as the camera and monitor.

(4) Portable laparoscopic trainer for smartphones and tablets—Surgicaltrainer based on iPhone Technology (Escamosa, Ordorica, et. al., 2014and 2015)—This trainer has a folding plastic base to hold a smartphone.The surgical field is limited and surgical instruments have a verylimited range of motion.

(5) Cardboard box iTrainer (Ruparel, Brahmbhatt, et. al., 2014)—This afolding open box surgical trainer with a tablet and very limitedsurgical space to manipulate instruments.

(6) LapSkills from Innovus (http://www.inovus.org/#lap-skills/c380accessed 20 Jun. 2016)—This is a box surgical trainer used with asmartphone. It has very limited surgical space and does not allow muchfreedom of motion for surgical instruments. The position of the tabletor phone is fixed.

(7) eoSim (http://www.eosurgical.com accessed 20 Jun. 2016)—This is abox trainer used just to manipulate physical items, i.e., no animalmodels can be used with this trainer. The surgical field is reduced intoa limited box area and the surgical tools are inserted into a fixedlocation without the use of trocars. The tablet or phone is also in afixed position.

(8) Card Board Box iTrainer (Van Duren and Van Boxel, 2014)—This is acard board surgical trainer that uses the camera in a smartphone as alaparoscope and a tablet computer as an external screen monitor Thesurgical instruments are at a fixed location and are used to manipulatephysical items only. The tablet or phone are in a fixed position.

All the current box trainers discussed above are relatively portable,easy to use, and inexpensive. They all use real surgical tools and allthe box trainers use smartphones, tablet computers or both as asurrogate for a laparoscope. The majority of these box trainersintroduce surgical instruments into the visual field of the smartphoneor tablet though holes in a cardboard enclosure or holes in plasticdiscs integrated with the box trainer enclosure.

All the box trainers discussed above also have the followinglimitations. They all entail a very limited surgical field. This meansthat surgical tasks can only be performed on physical models or verysmall animal models. Additionally, the instruments as used in the boxtrainers have a greatly reduced range of motion and in many caseslimited degrees of freedom to move. The smartphone and tabletsfunctioning as a laparoscope surrogate and/or external monitor are alsoin a fixed position. Thus, the surgical field cannot be moved, which isa problem since laparoscope movement in conjunction with instrumentmovement is an important surgical coordination task but also the fixednature of the surgical field limits the size of the models that can beused for surgical tasks. Also, because of the symmetric design ofcurrent box simulator instrument holders and the eccentric placement ofthe camera on third party devices, such as tablet computers andsmartphones, instrument spacing in the visual field of the simulator isnot representative of a real surgical scenario. Finally, surgicalinstruments cannot be placed through trocars in any of the current boxsimulators.

SUMMARY OF THE INVENTION

Embodiments of the current invention can be used with a cell phone,smartphone, tablet, and mini-tablet computer. The instrument holdersused with these devices in most embodiments are not symmetricallydesigned to permit realistic spacing in the surgical field especiallywhen viewed on an external monitor. For example, embodiments of thisinvention often include a right instrument holder arm that is longer andbent along its longitudinal axis because the camera location on thesmartphone, tablet or mini-tablet computer functioning as a surrogatelaparoscope is in the upper left corner of these devices. In someembodiments the instrument holders also terminate in ball jointspermitting free motion simultaneously in two planes. Also, the hole inthe ball joint in which the surgical instrument is inserted has asufficiently large diameter that vertical displacement and free rotationof surgical instruments about the surgical instrument shaft is permittedas well as insertion through trocars. This significantly enhances thesurgical instrument range and freedom of motion approaching that of areal surgical scenario as compared with current box trainers. In someembodiments the internal camera acting as a laparoscope can be moved inconjunction with or independent of surgical instrument motion ascompared with fixed locations on current box trainers. This also allowsa greatly enlarged surgical field permitting surgical training tasks tobe performed on large animals, as well as improved realism andsimulation of hand-eye coordination skills required in actuallaparoscopic and other minimally invasive surgeries.

In some embodiments, the smartphone, tablet of mini-tablet computer isfixed on a gimbaled central platform within a nest of two concentricgimbal rings attached to a support frame. The nested gimbal rings pivotand freely rotate about all three orthogonal axes of the centralplatform. The stylus of the smartphone, tablet, or mini-tablet computeris held in a fixed position over the smartphone, tablet, or mini-tabletcomputer. Motion of the stylus and the associated movement of thesmartphone, tablet, or mini-tablet computer causes rotations about theseaxes. The three-axis accelerometer internal to most smartphones,tablets, or mini-tablet computers fixed on the central platform detectsthese movements and are streamed and displayed to an external monitor.Apps can also be downloaded to the smartphone, tablet, or mini-tabletcomputer permitting games to be played using the stylus as a controllerthat promote development of relevant hand-eye coordination skills invarious minimally invasive surgical scenarios and entertainment gamescenarios. In some embodiments the eyepiece assembly is from anendoscope, gastroscope, colonoscope, bronchoscope, laparoscope, or realsurgical tool adapter that a gastrointestinal clinician or surgeonmanipulates can replace the stylus above. Streaming various VR surgicalscenarios to an external monitor then permits simulation of variousendoscopic and minimally invasive surgical procedures.

BRIEF DESCRIPTION OF THE DRAWINGS

Embodiments are illustrated as examples and do not connote limitationsin the figures of the accompanying drawings. There are five embodimentsof the subject invention illustrated in the accompanying drawings—FIGS.1 through 15.

The first embodiment of the subject invention is shown in FIG. 1. FIG. 1presents a system view of this first embodiment of the LaparoscopicSurgical Simulation and Training System. Detail 101 shows a monitor witha display, which could be a television. Detail 111 shows a wirelessdevice connecting the monitor 101 to a smartphone 105. Detail 105however could also be a tablet computer or mini-tablet computer. Theconnection between the monitor 101 and the device 105 could be a directwired connection or wireless connection. Detail 111 is not necessary ifa directly wired connection is used to connect 105 to 101. An example ofa device 111 used for a wireless connection between 105 and 101 could beApple TV® if the monitor 101 was a television. Left and rightlaparoscopic tools are shown as details 108 and 102, respectively. Astand, shown as a tripod in FIGS. 1, 6 and 8, with feet 107 and astationary fixed axis, 106, provides stability and a stationary positionfor the device 105 and associated laparoscopic instrument holders. Thisstand however could be any commercial “off-the shelf” stable platform.

The left and right arms, 112 and 115, of the laparoscopic instrumentholders are shown in FIG. 2. The left and right instrument holders atthe distal ends of their arms have plates 109 and 103, respectively,with embedded ball joints, 110 and 104 shown in FIG. 3. The assembledinstrument holders with embedded ball joints are shown in FIG. 4.Laparoscopic instruments, 102 and 108 (FIG. 1), are inserted throughholes in the ball joints, 110 and 104. This permits the surgical tool tobe rotated about its axis, control depth of penetration, and displacethe tip of the tool in the visual field of the camera, vertically andhorizontally, by employing an appropriate displacement of the balljoint.

A second embodiment of the assembled instrument holders is shown in FIG.5 where plates, 113 and 114 are joined along their proximal edges ormanufactured as one piece. In this embodiment the connected plates, 113and 114, of the instrument holders form a flat surface for use as aplatform for the attachment of a smartphone, 105, tablet or mini-tabletcomputer.

FIG. 6 shows a third embodiment of the laparoscopic surgical systemwhere a smart phone case holder, 301, with integrated instrument holdersis employed. FIG. 7 shows the assembled case holder, 301, withinstrument holder arms, 302 and 303, attached to the plate 304 of saidcase holder, 301. The dimensions of the case holder, 301, could also bescaled with larger dimensions to accommodate the larger form factor of atablet or mini-tablet computer.

FIG. 8 shows another embodiment of the surgical simulation and trainingsystem integrated with a tablet, or mini-tablet computer, 401. FIG. 9shows the assembled laparoscopic instrument holders with longer arms toaccommodate the larger size of the tablet or mini-tablet computer ascompared with a smartphone, 105, shown in FIGS. 1 and 6. Plates 113 and114 located proximal on the instrument holder arms, 402 and 403, areattached securely to the tablet or mini-tablet case but could also beattached to an assembly 301, as shown in FIGS. 6 and 7, scaledappropriately to accommodate the larger form factor of a tablet ormini-tablet computer.

Another embodiment of this invention is shown in FIG. 10. FIG. 10 showsa surgical system for simulation and training incorporating a set ofthree nested, concentric gimbal rings attached to a stationary supportstructure, 501, with a semicircular support frame with a left half, 519,and a right half, 520, shown in FIGS. 10, 11, and 12. The set ofconcentric nested rings, 503, and 504, and central support platform,505, for the smartphone, 105, have orthogonal pivot axes.

The stylus, 502, in FIG. 10, or eyepiece assembly of a lapraroscope,endoscope, gastroscope, colonoscope, or bronchoscope is inserted into ahole, 509, shown in FIG. 11 and in the plan view of the centralplatform, 505, shown in FIG. 15. This hole is on the center of asemicircular arch structure, 508, spanning the front facing surface,507, of the central circular platform or annulus, 505, concentric withthe gimbal rings 503 and 504 and semicircular support frame with halves,519 and 520. Although a smartphone, 105, is shown for the embodiment inFIG. 10, the dimensions of the rings, 503 and 504, support structure,501, 519, and 520, and central platform, 505, and arch, 508, over theplatform, 505, could easily be scaled to accommodate the larger formfactor of a tablet or mini-tablet computer.

Motion of the stylus, 502, or alternatively an aforementioned surgicalscope, mounted over the smartphone, 105, tablet or mini-tablet computer,causes rotational displacements about the orthogonal axis of theconcentric gimbal rings, 503 and 504, and the concentric centralplatform, 505. The rotational displacements are sensed by an independentthree-axis accelerometer mounted on the central support platform, 505,or a three-axis accelerometer internal to a smartphone, 105, in FIG. 10,tablet or mini-tablet computer.

The semicircular portion of the support frame, 519, is connected to theouter gimbal ring, 503 with shaft, 518, shown in FIG. 11 The oppositehalf of the support structure, 520, is connected to the outer gimbalring, 503, with a similar shaft co-linear and aligned with 518. Theshaft, 518, in FIG. 11 is connected to a hole or bushing shown as detail516 in FIG. 13 and a complementary hole or bushing on 519 in FIG. 12.Detail 515 shown in FIG. 13 represents another hole or bushingconnecting a similar shaft to a complementary hole or bushing on 520 inFIG. 12. The two co-linear and aligned shafts connecting 503 to thesemicircular regions of the support structure, 519 and 520, permitrotation of 503 about a single axis established by the twoaforementioned shafts. This axis hereinafter will be referred to as the“roll axis.” This roll axis defined by these two co-liner and alignedshafts are parallel to the “ground plane” established by the supportbase, 501, in FIG. 12.

The outer gimbal ring, 503, is also connected to the inner gimbal ring,504, using two short shafts, 522 and 523, shown in FIG. 11 connecting514 in FIG. 13 to 510 in FIG. 14 and 517 in FIG. 13 to 511 in FIG. 14.Both shafts connecting 503 to 504 are aligned and co-linear and permitrotation of the inner ring, 504 about a single axis defined by thealignment of the two shafts connecting 503 to 504. This axis isorthogonal to the roll axis defined by 518. This axis hereinafter willbe referred to as the “yaw axis.”

A smartphone, 105, tablet or mini-tablet computer is securely mounted onthe innermost gimbaled platform, 505, shown in isometric views in FIGS.10, 11, and in plan view in FIG. 15. The circular platform, 505, can bea disc or annular structure that is concentric with the semi-circularsupport structure, 519 and 520, and outer and inner gimbal rings, 503and 504, respectively.

The circular platform, 505, has two holes or bushings, 518 and 517 inFIG. 15. The inner gimbal ring, 504, is connected to the platform, 505,using two shafts, 506 and 521, shown in FIGS. 10 and 11. The shaft 521is connected to a hole or bushing, 512, on 504 in FIG. 14 and a hole orbushing, 518 in FIG. 15. The shaft, 506, is connected to a hole orbushing, 513, on 504 in FIG. 14 and a hole or bushing, 517 in FIG. 15.The two shafts, 506 and 521, connecting 504 to 505 are aligned andco-linear establishing a single axis of rotation of 505 with respect to504. This axis of rotation is orthogonal to the aforementioned yaw androll axis and will henceforth be referred to as the “pitch” axis.

A semi-circular arc structure, 508, in FIGS. 11 and 15, spans the frontsurface, 507, of the platform, 505, and is fixed to 505 so it remainsstationary with respect to 505. A stylus, 502 (FIG. 10), is inserted ina hole, 509 (see FIGS. 11 and 15) in the semi-circular arc structure,508. Alternatively, the eyepiece assembly of a surgical scope, such asan endoscope, laparoscope, colonoscope, gastroscope, or bronchoscopecould be used in place of the stylus depicted in FIG. 10.

Motion imposed by the user on the stylus, 502, or surgical eyepieceassembly imposes rotational displacements about the roll, yaw, and pitchaxes of the central platform, 505, and the nested gimbal rings, 503 and504. These displacements are detected by the three-axis accelerometerinternal to the smartphone, tablet, or mini-tablet computer and mountedon the central platform, 505. Alternatively, an independentaccelerometer can be mounted on 505 for this purpose. Output from thethree-axis accelerometer used independently or internally in asmartphone, tablet, or mini-tablet computer results in inducing motionof an icon or virtual surgical instrument on the monitor, 101, or 105device as the concentric gimbals produce roll, yaw, and pitchdisplacements. The device 105 and the display 101 are connectedwirelessly using a device 111 or wired directly. By example, if 101 is atelevision and connected wirelessly to an IPhone®, 111 could be AppleTV®. If 105 is wired directly to 101, then 111 is not necessary.

DETAILED DESCRIPTION OF THE INVENTION

Disclosed herein are five embodiments of the subject invention. Theseembodiments are illustrated as examples and do not connote limitationsin the figures or the narrative description of the examples or theaccompanying drawings. All dimensions discussed for each examplerepresent a tested prototype and are included for pedagogic purposes tothose skilled in the art as an application of the inventive disclosurebut are no means meant to be limiting.

Various embodiments of laparoscopic instrument holders used in asurgical simulation system are described in examples one through fivedescribed below. Example 5 consisting of nested gimbal rings, can befurther used for simulation of endoscopic, colonoscopic, gastroscopic,and brochoscopic minimally invasive surgical procedures when used witheyepiece assemblies typical of the aforementioned surgical scopes. Thesmartphone, tablet, or mini-tablet computer in example 5, can also beused with downloadable applications (“apps”) or “games” that promotedevelopment of hand-eye coordination skills when used with a stylus.

EXAMPLES Example 1

Surgical Simulation and Training System with Laparoscopic InstrumentHolders Integrated with Smartphone (see FIGS. 1, 2, 3 and 4). A uniquefeature of this embodiment are the design of the laparoscopic instrumentholders shown in FIG. 4. These holders can accommodate any smartphonecase and consist of a separate left and right arm, 112 and 115,respectively.

The shape and dimensions of the instrument holder arms, 112 and 115, arenecessarily different. Each arm has a distal and a proximal end. Thedistal end of each arm terminates in a ball joint, 110 and 104. Theproximal end of each arm is attached to the case of the smartphone, 105,in FIG. 1. The shape and dimensions of the arms, 112 and 115, howeverare different because the camera internal to a smartphone, 105, istypically eccentrically located on the rear surface of the smartphone.Often the internal smartphone camera is located in the upper left handcorner. Thus, the right arm, 115, must be longer to preserve spacing ofsurgical instrument tips that are representative of a real surgicalscenario. This spacing is nominally 10 cm so the right arm, 115, inorder to be closer to the surgical field for a camera eccentricallylocated on the upper left corner on the rear of the smartphone, must belonger and angled inward toward the surgical field, relative to the leftinstrument holder arm, 112. Laparoscopic instruments, 108 and 102 inFIG. 1, are inserted in the ball joints, 110 and 104, at the distalterminus of the arms 112 and 115. These instruments, 108 and 102, aregrasped by the left and right hands of the surgeon, respectively.

When the laparoscopic instrument holders are attached to the smartphonecase, the smartphone camera can then function as a surrogate laparoscopefocused on the surgical field and streamed to an external monitor, 101in FIG. 1 in “real-time” (i.e., without apparent latency in the videostreaming). The integrated surgical simulation and training system thenconsists of laparoscopic instruments, 108 and 102, inserted through theball joints, 110 and 104, at the distal terminus of the aforementionedlaparoscopic instrument holders, and attached to a smartphone case, andwhere “real-time” video images from the internal camera of said case arestreamed to an external monitor 101. Once the instrument holders havebeen attached to the phone case, the distance between distal ends of thesurgical instruments (that is the end of the surgical instrument in thesurgical field) should be approximately 10 cm representative of a reallaparoscopic surgical scenario. The instrument holders, 112 and 115, inthis embodiment are separate so the user can locate and positon the armsaccording his needs and the specific design of the smartphone andrear-facing smartphone camera location.

The remaining text in the description of this example will discuss thespecific dimensions and design of the prototype arms that were used andtested by the inventor. These dimensions are for illustrative purposesonly and should not be construed as connoting any limitations. They aremerely provided for pedagogic purposes to instruct someone skilled inthe art as to an application of the disclosed invention.

The left instrument arm consisting of 109, 110, 112, and 113 (FIG. 4)was 143.86 mm long. The left instrument holder arm, 112, was 10 mm wideand 3 mm thick. When injection molded from an appropriate plastic resin,the mechanical stiffness of the instrument holder arms was sufficientlyrigid to hold and manipulate the laparoscopic instrument insertedthrough the respective ball joints, 104 and 110, located at the distalend of each arm, 112 and 115. The proximal end of each instrument holderarm, 112 and 115, had a 25 mm² square and approximately 8 mm thickplanar surface, 113 and 114, that was attached to smartphone case andprovided sufficient stability when laparoscopic instruments were used toperform surgical maneuvers with the surgeon's left hand.

Distal to the to this smartphone attachment plate 113, along the leftarm, 112, there was a 90 degree step in the arm located 34.93 mm distalto the plate 113 distal boundary. The step was proceeded and followed bybends in the arm, 112, with a 4.0 mm radius. These bends mitigatedstress risers when the arms are manipulated but also correctly positionthe arm segment distal to this step. Because of these bends, the 44.23mm arm segment distal to the step was actually at a subtended angle of95 degrees. Distal to this arm segment was a 7.20 mm thick, squareplanar surface, 109, with rounded edges that was 40 mm² that forms thedistal terminus of this instrument holder. This distal terminal plate,109, had a spherical space with a 31.2 mm radius to accommodateplacement of a ball joint, 110. In the center of the ball joint was an8.20 mm diameter hole where a surgical port was introduced andlaparoscopic instruments with a nominal 5 mm diameter shaft wereinserted. There was sufficient play between the 5 mm diameter instrumentshaft and 8.2 mm hole in which the instrument is inserted that thesurgical instrument could be displaced along its longitudinal axis topermit varying depths of penetration in the surgical field as well asrotation about the surgical instrument shaft. The ball joint alsopermitted displacements along two orthogonal axes in the plane of thedistal terminal plate, 110.

The right arm, 115, is also 10 mm wide and 3 mm thick with a totallength of 116.17 mm with three bends approximating the shape of an “S”because it must be closer to surgical field due to the eccentriclocation of the rear-facing, internal smartphone camera. At the proximalend of the right arm, 115, there is an 8 mm thick, 25 mm² square plate,114, that attaches to the smartphone, 105. Distal to this smartphoneattachment plate, 114, along the right arm, 115, there is a 90 degreestep in the arm located 33.79 mm distal to the plate 114, boundary. Thelongitudinal axis of the arm segment distal to this step is 51.17 mm inlength and angled 135 degrees with respect to the longitudinal axis ofthe right arm proximal to the 90 degree step. Again there is anotherbend at the distal end of the right arm so that the plane of the distalterminal plate, 103, is at a 145 degree angle with respect to thelongitudinal axis of the right arm segment attached to this terminalplate. The design of this terminal plate, 103, and associated balljoint, 104, is identical to the same elements, i.e., 109 and 110, in theleft instrument holder arm.

Example 2

Surgical Simulation and Training System with “Joined” LaparoscopicInstrument Holders Integrated with Smartphone (see FIG. 5). The onlydifference between the previous example with separate right and leftinstrument holders and this example, is that the proximal terminalplates, 113 and 114, are fixed at their proximal edges or can bemanufactured as one piece. This gives enhanced stability at thesmartphone attachment point to the arms and maintains the same distancebetween distal ends of instrument holder arms. One advantage of thismodel is that the user can install the smartphone quickly withoutadjusting the arms since the distance between distal ends of theinstrument holders are maintained.

Example 3

Surgical Simulation and Training System with Laparoscopic InstrumentHolders Integrated with Smartphone, and Smartphone Case Holder (seeFIGS. 6 and 7). This embodiment includes a universal smartphone case,301, in FIGS. 6 and 7, that can accommodate any sized smartphone, withattached right and left instrument holders. The phone case, 301, astested, was rectangular and 164.94 mm long, defined by detail 305, and76 mm high, defined by detail 304, to accommodate the largestsmartphones currently available. The instrument holders in FIG. 7, had afixed distance between the ball joint centerlines of. 248.81 mm.However, the smartphone case was be mounted on a commercially availableportable stand such as the tripod, 106 and 107, shown in FIG. 6, so thatthe initial position and location of the distal tips of laparoscopicsurgical tools in the surgical field were prescribed to the nominal 10cm.

The arm of the left instrument holder, 302, was 148.81 mm long, alongthe longitudinal axis of the arm, 10 mm wide and 3 mm thick, and couldbe divided into at least four sections, not including the distal plate,109, with the ball joint, 110. There was a 69.94 mm section parallel tothe phone case holder length and horizontal with respect to the groundplane. The proximal end of this section was attached to a diagonalsection that rose vertically a distance of 9.02 mm over the left cornerof the smartphone case, detail 304. This permitted the camera to recordvideo or photos. The distal end of this 69.94 mm section had a thirdsection that was 34.01 mm in length and was at right angles,perpendicular to the plane of this 69.94 section. The fourth section ofthe left arm, 302, was another 42.34 mm segment at 95 degrees to thelongitudinal axis of the 34.01 mm segment and distal to the 34.01 mmsegment. Distal to the 42.34 mm segment was the terminal plate, 110, andball joint, 109. The design of 110 and 109 as well as the configurationof the associated laparoscopic instruments was identical to the firstthree examples.

The right arm, 303, in this example has a 53.40 mm segment normal to theplate 304 as depicted in FIG. 7. There is a another 25.99 mm segmentdistal to the 53.40 mm segment where the longitudinal axis of thissegment and the previous right arm segment subtends an angle of 135degrees. The geometry of the left and right instrument arms, 302 and303, permit a much larger surgical field then would be possible withcurrent box trainers and allows laparoscopic procedures to be performedon larger animal models.

Example 4

Surgical Simulation and Training System with Laparoscopic InstrumentHolders Integrated with a Tablet Computer (see FIGS. 8 and 9). The leftand right arms, 402 and 403, respectively, of the separate left andright instrument holders in this example were similar to the instrumentholders in example 1. However, the tablet or mini-tablet computer, 401,in FIG. 8, had a larger form factor than the smartphone, 105, in theprevious examples. Because of the larger form factor of 401 relative to105, the distance between attachment points of the instrument holders onthe 401 case was larger than the distance between the left and rightinstrument holders in example 1. As a consequence, the instrumentholders in this example were necessarily longer than the respectiveinstrument holders in example 1 and the distance between 401 and thetarget tissues and organs of the animal models that 401 images in thesurgical field were father than the corresponding distance in example 1.

The arm, 402, of the left instrument holder measured along itslongitudinal axis was 212.37 mm long, 10 mm wide, and 3 mm thick. Thearm, 402, terminates proximally in a 7.82 mm thick, 40.14 mm² squareplanar surface, 113, which is attached to the tablet or mini-tabletcomputer holder providing stability when laparoscopic instruments aremanipulated with the surgeon's left hand. As in previous examples, thedistal terminus of this arm is a planar surface 109 and ball joint, 110.Laparoscopic instruments are inserted in to the ball joints as inprevious examples.

The arm, 402, of this left instrument holder had two 90 degree bendsgiving a “Z” like shape to this arm as shown in FIG. 9. The location ofthe first bend was 54.63 mm distal to the planar surface, 109, edgewhere the arm 402 was attached. Distal to the first bend closest to theplanar terminus 109, there was a 62.97 mm arm segment perpendicular toaforementioned 54.63 mm segment. Distal to this 62.07 mm segment therewas another 54.63 mm segment perpendicular to the aforementioned 62.97mm segment which formed a lap joint with planar surface 113. The designof this arm provided increased access to the left surgical field bylaparoscopic instruments as compared with current box trainers.

The arm, 403, of this right instrument holder was 249.26 mm as measuredalong the longitudinal axis of 403 and has three bends rendering an “S”shape as shown in FIG. 9. The shape of this arm was dictated by the needto be closer to surgical field given the eccentric location of theinternal camera in 401. The arm, 403, terminated proximally forming alap joint with a planar surface, 114. The design of 114 was identical tothe corresponding surface 113. Both 113 and 114 are attachment to the401 case. Distal to this proximal planar surface was a short segment ata 90 degree bend leading to 91.46 mm long segment. Distal to this 91.46mm segment there was another short segment at 135 degrees relative tothe previous 91.46 mm segment. There was then another 67.54 mm segmentat 145 degrees relative to the previous short segment. The shape andincreased length of this instrument holder preserved the nominal 10 cmspacing of laparoscopic surgical tips in the surgical field given theeccentric location (upper left corner) of the rear facing internalcamera in 401.

Example 5

Concentric Nested Gimbal Ring Surgical Simulation and Training SystemIntegrated with a Smartphone (see FIGS. 10 through 15). Example 5describes another embodiment of this invention shown in FIG. 10. FIG. 10shows a surgical system for simulation and training incorporating a setof three nested, concentric gimbal rings attached to a stationarysupport structure, 501, with a semicircular support frame with a lefthalf, 519, and a right half, 520, shown in FIGS. 10, 11, and 12. The setof concentric nested rings, 503, and 504, and central support platform,505, for the smartphone, 105, have orthogonal pivot axes.

Motion imposed by the user on the stylus, 502, or surgical eyepieceassembly imposes rotational displacements about the roll, yaw, and pitchaxes of the central platform, 505, and the nested gimbal rings, 503 and504. These displacements are detected by the three-axis accelerometerinternal to the smartphone, tablet, or mini-tablet computer and mountedon the central platform, 505. Alternatively, an independentaccelerometer can be mounted on 505 for this purpose. Output from thethree-axis accelerometer used independently or internally in asmartphone, tablet, or mini-tablet computer results in inducing motionof an icon or virtual surgical instrument on the monitor, 101, or 105device as the concentric gimbals produce roll, yaw, and pitchdisplacements.

In this particular example, a smart phone was mounted on the centralsupport platform, 505. The central platform was 12.50 mm thick andcircular with a 90 mm radius. The arch structure, 508, was 15 mm wideand 4.65 mm thick and was normal to the surface, 507. At the highestpoint of the arch, the arch was 46.79 mm normal to the surface 507. Thecentral platform, 505, was sized in this example to accommodate asmartphone or mini-tablet computer. The hole, 509, had a 5 mm radius,sufficient to accommodate a stylus, or the eyepiece assembly of anendoscope, gastroscope, colonoscope, bronchoscope, laparoscope, or realsurgical tool adapter as a controller; i.e., the device that the userdisplaces to induce apparent motion on an external monitor, 101.

The central platform, 505, was attached to the inner gimbal ring, 504,using a shaft 506 and 521, with a 5.83 mm shaft radius. This shaftestablished a single axis of rotation. The inner gimbal ring, 504, had aradius of 125 mm and a 12.50 mm width. The inner gimbal ring, 504, wasseparated from the outer gimbal ring, 503, by 2.50 mm and 503 had aradius of 140 mm. The outer gimbal ring, 503, was similarly separatedfrom the semicircular support frame, 519 and 520, by 2.50 mm. Eachconcentric ring, 503, and 504, and the central support structure, 505,pivoted orthogonal to each other using shafts that had a 5.83 mm shaftradius. Each gimbal ring and the support structure were capable offreely rotating a full 360 degrees about the roll, yaw, and pitch axisas previously described.

The stand, 501, used in this example had a base with a segment parallelto the ground plane and a segment at a 65 degree angle from the base.The segment parallel to the ground plane was 12.50 mm thick and 184.87mm deep as measured along the normal from the angled base and 235. mmwide. Attached to this angled segment was a semicircular support framewhere the semicircle was concentric with the two gimbal rings, 503 and504, and the circular central support structure, 505. The height of thesemicircular support frame, 519 and 520, and attached base, 501, was377.88 mm above the ground plane. The external diameter of thesemicircular support frame, 519 and 520, was 310 mm. The 65 degree angleof the support frame was designed to simulate the tilt of the abdominalsurface in a real surgical scenario.

Other Embodiments

The detailed descriptions set-forth above are provided to aid thoseskilled in the art in practicing the present disclosure. However, thedisclosure described and claimed herein is not to be limited in scope bythe specific embodiments herein disclosed because these embodiments areintended as illustration of several aspects of the disclosure. Anyequivalent embodiments are intended to be within the scope of thisdisclosure. Indeed, various modifications of the disclosure in additionto those shown and described herein will become apparent to thoseskilled in the art from the foregoing description, which do not departfrom the spirit or scope of the present inventive discovery. Suchmodifications are also intended to fall within the scope of the appendedclaims.

What is claimed is:
 1. A surgical simulation and training systemcomprising: a stand supporting a video camera and right and leftlaparoscopic instrument holders wherein said stand can be moved toenlarge the visual field of said camera and said stand remains stableduring movement of said laparoscopic instrument holders; a targetcomprising a physical model, animal model, physical model of the humananatomy, or virtual model of the human anatomy and combinations thereof;a monitor displaying the visual field of said video camera focused onsaid target; a said left and a right laparoscopic instrument holder,each with a proximal end and a distal end, where said distal end of saidinstrument holder terminates in a ball joint and said proximal end isattached to said video camera case, and said ball joint of saidinstrument holder has a completely penetrating hole sized to accommodatethe diameter and free rotation of the shaft of a laparoscopic surgicalinstrument including a laparoscopic instrument used with a trocar. 2.The surgical simulation and training system comprising: a standsupporting a left and a right laparoscopic instrument holder and adevice 1 with an internal video camera chosen from the group consistingof a cell phone, smart phone, tablet and mini-tablet computer, wheresaid stand can be moved to enlarge the visual field of said device 1internal camera and said stand remains stable during movement of saidlaparoscopic instrument holders; a target comprising a living animal,physical model of the human anatomy, or virtual model of the humananatomy and combinations thereof; a monitor displaying the visual fieldof said device 1 internal camera focused on said target; a said left anda right laparoscopic instrument holder, each with a proximal end and adistal end, where said distal end of said instrument holder terminatesin a ball joint and said proximal end is attached to said device 1 case,and said ball joint of said instrument holder has a completelypenetrating hole sized to accommodate the diameter and free rotation ofthe shaft of a laparoscopic surgical instrument including a laparoscopicinstrument used with a trocar. a said left and a right laparoscopicinstrument holder wherein the size and shape of said instrument holderarms are designed to preserve a nominal spacing of surgical instrumenttips in said target visual field as used in real laparoscopic surgeriesthat is nominally 10 cm.
 3. The surgical simulation and training systemrecited in claim 2, wherein said device 1 is placed in a holder attachedto said support stand with said left and right laparoscopic instrumentholders attached to said holder along said proximal ends of saidlaparoscopic instrument holders.
 4. The surgical simulation and trainingsystem recited in claim 2, wherein said left and said right laparoscopicinstrument holders are attached at said proximal edges.
 5. The surgicalsimulation and training system recited in claim 2, wherein said rightlaparoscopic instrument holder is longer than said left laparoscopicinstrument holder and said right laparoscopic instrument holder isangled inward toward said target visual field.
 6. A surgical simulationand training system recited in claim 2 wherein software applications canbe downloaded to said device 1 permitting games to be played using saidcontroller to promote development of relevant hand-eye coordinationskills in various minimally invasive surgical scenarios andentertainment game scenarios
 7. A surgical simulation and trainingsystem comprising: a device 2 chosen from the group consisting of a cellphone, smartphone, tablet and mini-tablet computer fixed to a centralsupport structure, where said central support structure is pivotedallowing rotation of said central support structure about a single axisdefined by a shaft joining the central support structure to aconcentric, externally mounted first ring; a game controller joystick ina fixed orientation within 45 degrees of the outwardly facing normal tosaid device 2, wherein said controller is grasped by the user andinduces motion of said central support structure, and wherein saidcontroller is chosen from the group consisting of a stylus, the eyepieceassembly of a fiber optic surgical scope, and a surgical tool adapter; afirst ring concentric with and mounted external to said central supportstructure where said first ring is pivoted with respect to said centralsupport structure allowing rotation of said first ring about a singleaxis orthogonal to said central support structure; a second ringconcentric with and mounted external to said first ring that is pivotedwith respect to said first ring allowing rotation of said second ringabout a single axis orthogonal to said central support structure andsaid first ring; a support frame concentric with and external to saidcentral support structure, said first ring, and said second ring, wheresaid support frame remains stationary during induced motion by said gamecontroller and permits independent rotation of said first ring, saidsecond ring and said central support structure about orthogonal axes andaccess and movement of said controller by the user is unimpeded.
 8. Asurgical simulation and training system recited in claim 7 wherein saiddevice 2 is replaced by a three axis accelerometer.
 9. A surgicalsimulation and training system recited in claim 7 wherein softwareapplications can be downloaded to said device 2 permitting games to beplayed using said controller to promote development of relevant hand-eyecoordination skills in various minimally invasive surgical scenarios andentertainment game scenarios.
 10. A surgical simulation and trainingsystem recited in claim 7, wherein said stand is comprised of a baseparallel to the ground plane and said support frame attached to saidbase wherein said support frame is at an angle with respect to said baseto approximate a plane tangent to a body contour.